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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010145
Report Date: 05/10/2023
Date Signed: 05/10/2023 05:14:47 PM

Document Has Been Signed on 05/10/2023 05:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NGUYEN, HOANG FCCHFACILITY NUMBER:
493010145
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 4CENSUS: 3DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:Hoang "Kim" and Matthew NguyenTIME COMPLETED:
04:30 PM
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An annual required inspection was made to the facility by Licensing Program Analysts (LPA), Y. Yang and S. Mariani. A review of staff records on 05/10/2023 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. There are currently two adults living in the home.

During today’s inspection the home and grounds were toured. The licensee and an assistant was supervising three children. The facility’s operating hours are 07:30am to 05:30pm, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The children have access to the living room, dining room, hall bathroom, and office. The off-limits areas of the home were made inaccessible by door locks and/or child gates. The two fireplaces in the home have been covered and made inoperable. The home was observed to be clean and orderly, and was at a comfortable indoor temperature. There were safe toys and equipment available for children. The licensee stated there is a working telephone in the home. The licensee’s pediatric CPR and First Aid certifications and CA mandated reporter training certificates were reviewed and expire April 2025 and 03/30/25, respectively. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. The LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The licensee stated that poisons are stored in a key locked shed in the home's backyard. The licensee states there are no firearms, ammunition, or other weapons in the home. The children use part of the home’s fully fenced backyard as the outdoor play area. The area on limits to children is separated by a half fence and gate. There are no bodies of water on the premises Four children's records were reviewed during today's inspection. Children's immunization records, identification and emergency forms, and notification of parent's rights forms were on file. The LPA reviewed infant safe sleep check logs. The LPA provided information to the licensee regarding the requirement to complete infant safe sleep plan (LIC9227) for infants under the age of 12 months. Two staff records were reviewed and contained the required documents as specified in the inspection checklist. Continued on LIC 809-C
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NGUYEN, HOANG FCCH
FACILITY NUMBER: 493010145
VISIT DATE: 05/10/2023
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

During today's inspection visit, the LPAs inspected the facility for an increase of capacity application submitted by the licensee that was received by the Department on 04/27/23. The licensee is requesting a capacity increase to 14 children. The fire clearance was received by the licensee on 05/08/23. The capacity increase is approved effective today's date.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensees, Kim and Matthew Nguyen. There were no Title 22 deficiencies cited during today's inspection.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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